PEYTON – 17011

DVM Intake Exam

Estimated age: 6yrs
Microchip noted on Intake? none
Microchip Number (If Applicable):

History : found in apartment with other cats- o is in the hospital

Subjective: docile, friendly, in spite of painful injury

Observed Behavior – no aggression allows all handling

Evidence of Cruelty seen -no

Evidence of Trauma seen -yes

Objective

P =180
R =24
BCS 6.5/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: moderate dental tartar, resorptive lesion in the upper L dental arcade, chipped R maxillary canine- non painful when touched
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: slightly tense, but non painful, no masses palpated
U/G: FS, visible spay scar seen after shaving
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. 3rd digit on RH- quick exposed (nail broken). On L FL- digit 3’s nail embedded approx 0.5cm. Moderately swollen foot with open wound on dorsal aspect of foot.
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment
R HL: broken nail, quick exposed
L FL: embedded nail with secondary swelling and fistula
moderate dental dz with resorptive lesion, chipped R maxillary canine

Prognosis: good

Plan:
gave simbadol (1.8mg/ml) 0.7ml SQ at 5PM; then SID x 2 more days
gave convenia (80mg/ ml) 0.6ml SQ at 5:15PM
cut off embedded nail, then soaked entire paw in chlorhexidine solution for 5 minutes
**shredded paper only until January 2, 2018 sign placed in cage packet
long term consider weight loss (approx 2 lbs over 4-5 months) and rec dental procedure with dental extraction of affected teeth- p has evidence of a resorptive lesion which can be painful. Cats may be affected by these tooth lesions that they can be genetically predisposed to.

SURGERY:
N/A, already spayed